2012 ALL PAYERS WORKSHOP
BLUE CROSS AND BLUE SHIELD OF KANSAS
AGENDA
Connecting with Providers
Other Party Liability (OPL)
Quality Based Reimbursement Program (QBRP)
Electronic Data Interchange (EDI)
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Blue Cross and Blue Shield of Kansas
Connected to our Providers
• Provider Representative
o Phone
 Call your BCBSKS Rep for inquiries
 Conference Call
o Fax
o Email
o Provider Visits
 One-on-one
 By Facility Department
• Training
o Workshops
o Web-based Training Modules
• eNews
o Newsletter
o Latest News
o Medical Policies
o Website Updates
• BCBSKS Website (www.bcbsks.com)
o Inquiries/Secure Web Form
o Manuals
• BlueAccess
o Policies & Procedures
o Precertification
o Remittance Advice
• Availity
o Eligibility
o Claim Status
• Webinars
• KHA Convention
• All Payers Workshop
• BCBSKS Contact Information on the Web
o Provider Representative
o Education Coordinator
o Claims Research Analyst
o EDI
o Professional Relations Hotline
o Customer Service Center
o Other Party Liability (OPL)
o Federal Employee Program (FEP)
o BlueCard
o Precertification Department
o Health Information Systems
o TRICARE
o New Directions
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BLUE CROSS AND BLUE SHIELD OF KANSAS
Other Party Liability (OPL)
The BCBSKS OPL Department focuses on cost containment by
coordinating payments between carriers. This saves millions of dollars
each year.
To contain costs, Blue Cross and Blue Shield of Kansas group health
contracts include a non-duplication of benefits provision. This ensures
that our customers do not receive duplicate payments for the same
claim through multiple group health insurance carriers. Payment
between two (or more) carriers may not exceed the total charge of the
claim.
Most contracts also include exclusions which deny benefits for
services eligible under a Worker's Compensation law or No-Fault
Automobile insurance.
Duplicate Coverage
Duplicate coverage applies when a patient is covered under more than
one group health insurance carrier. Benefits are coordinated by the
secondary carrier to prevent duplicating payment for the same service
made by the primary insurer.
Duplicate coverage is investigated on all new group family contracts.
Follow up investigations are conducted every 15 to 18 months on
those members who have indicated they have no duplicate coverage.
Since 2008, Other Party Liability (OPL) will not delay claims for
response to a routine duplicate coverage questionnaire. However, FEP
policies, large dollar claims, member pay and third party payees are
excluded.
When duplicate coverage exists, a claim should be filed to all carriers
(except in the case of multiple Blue Cross and Blue Shield of Kansas
group policies, when only one is necessary). The Order of Benefit
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Determination rule establishes a patient's primary carrier. Once
provided proof of primary payment, the secondary carrier will process
balances still owed by the patient for eligible benefits. A copy of the
actual primary Explanation of Benefits (EOB) should be submitted as
proof of primary payment, unless filing electronically. The electronic
837 claim format includes specific fields for reporting other insurance
information. Claims must be filed to all carriers involved within the
specified timely filing period of each.
Maintenance of Benefits (MOB)
ASO (Administrative Services Only) and out-of-area groups may
choose to apply Maintenance of Benefits to dual coverage, rather than
the standard Coordination of Benefits (COB) regulated by the NAIC
and State Model. MOB does not apply to Benefit Determination Period
nor does it ever allow the combined payments of carriers to exceed the
allowable charge, regardless of the provider's contracting status. In
some instances, the group has elected to hold the combined payments
to the amount payable by their policy as if it were the only insurance
coverage available. Groups currently using MOB include OneOK and
the Federal Employee Program (FEP).
Accidents
Accidents and other diagnosis frequently identified as being work or
automobile related (including back problems, carpal tunnel, heart
attacks and hernias) are investigated for the possibility of another
carrier who may be liable. Claims meeting the dollar threshold set by a
Plan are reviewed for information regarding the date, place and
circumstances of injury or onset of illness. If none exists, a
questionnaire is sent to the member. Medical records are accepted in
lieu of the member's response when necessary details are present.
The member’s file is updated after an investigation has been
completed to prevent multiple investigations of the same accident or
condition.
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Worker's Compensation
Worker's Compensation insurance provides benefits when an
employee suffers a job related injury or illness. Blue Cross and Blue
Shield of Kansas excludes coverage for services covered (or required
to be covered) under a worker's compensation law. If the employee
receives services from an unauthorized provider, or enters into a
settlement giving up their right to future medical benefits, related
claims will not be eligible under their BCBSKS policy. A letter of denial
or release from the worker's compensation carrier should be forwarded
to BCBSKS for reconsideration when applicable.
Auto No-Fault
Auto No-Fault or Personal Injury Protection (PIP) insurance benefits
apply to any accidental bodily injury that arises out of the ownership,
operation, maintenance or use of a motor vehicle. Those benefits must
be completely exhausted before BCBSKS can determine what, if any,
benefits BCBSKS will pay. A letter of denial or itemized statement of
PIP and Excess Medical payments is necessary to make that
determination.
The OPL Web Questionnaire
The OPL Questionnaire is available for our providers on the web at
http://www.bcbsks.com/CustomerService/Forms/pdf/34-704_OPL.pdf
It is recommended that providers ask patients insured by BCBSKS to
fill out the BCBSKS OPL web form with their other paperwork during a
provider visit. This enables the provider to mail or fax the completed
form prior to claim submission; providers can avoid delays otherwise
caused when an OPL investigation is necessary.
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Providers may also directly submit the information electronically via the
web at https://clyde.bcbsks.com/forms/opl?page=provider
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The Remittance Advice (RA)
The RA for secondary payments will show, not only the amount paid on
the secondary claim, but also the total amount paid by the primary carrier,
the total amount of patient responsibility, and the total provider write-off
after taking into consideration the benefits of both carriers. This eliminates
the need to retrieve the primary carrier EOB for balancing patient
accounts. There are specific coding combinations on the Remittance
Advice that help to identify a claim involving Other Party Liability.
To identify an OPL claim on the RA the CNTR column will state OP. The
OPL Adjustment Reason Code (ARC) and Remarks on the RA for OPL
claims are listed in the table below with the code defined.
ARC
Remarks
19
MA04
This service is due to a job-related illness or
injury covered by Worker's Compensation.
21
MA04
The services are Motor Vehicle related
22
MA04
The Primary Carrier must process first and an
Explanation of Benefits from the Primary Carrier
is required.
22
N48
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Code Definition
The Explanation of Benefits (EOB) from the
Primary Carrier does not match this claim.
Paid as secondary carrier
MA04
The patient has accepted a financial settlement
from another insurance company for this claim
23
M43
The Primary Carrier's payment exceeds the
amount payable under the patient's contract. No
Secondary Carrier payment is available on this
claim.
227
N179
Awaiting a response to an OPL Questionnaire
sent to the patient
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For FEP Members: Contact OPL Dept.
1-785-291-4013
1- 800-430-1274
FAX 785-291-8981
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Provider Remittance Advice Examples for Other Party Liability (OPL)
Awaiting a response to an Other Party Liability questionnaire sent to the patient.
CNTR = OP
ARC = 227 (FEP ARC = 16) Remit Remark = N179
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Provider Remittance Advice Examples for Other Party Liability (OPL)
Paid as secondary carrier…
CNTR = OP
ARC = 23 (FEP: call OPL)
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Primary carrier EOB from example above:
COB: Duplicate coverage secondary payment formula:
• Secondary balance - the amount owed by the patient after the primary
payment.
• Secondary payment -the secondary balance, not to exceed the amount
payable as primary.
Provider’s Contractual Obligation - the primary carrier’s write-off will be enforced.
Exceptions: 1) Secondary balance exceeds the BCBSKS allowed amount
2) Provider has no contracting arrangement with the primary carrier
Amount Patient Owes - remaining balance.
Note: MOB groups determine their own secondary payment rules
Workers Compensation: Services not work related must be submitted on a
separate claim from those services that are eligible under workers compensation
law.
No Fault: Payment after exhausting auto insurance (PIP) benefits is subject to
member’s contractual cost sharing (deductibles, coinsurance, etc.).
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BLUE CROSS AND BLUE SHIELD OF KANSAS
Quality Based Reimbursement Program (QBRP)
BACKGROUND
• QBRP is an element of the Patient Protection and Affordable Care
Act (also known as Healthcare Reform).
• It requires health plans to have a reimbursement arrangement that
incentivizes quality.
• QBRP is a requirement for a health plan to be eligible to participate
on the Health Insurance Exchange.
EXCHANGE TIMELINE
• The Exchange takes effect in 2014
• Health plan’s quality incentive programs will be evaluated for approval
in 2013.
QBRP CRITERIA FOR 2013
• BCBSKS worked with Kansas hospitals, Kansas Hospital
Association and the Kansas Healthcare Collaborative to develop
our QBRP.
• The goal is to associate provider's performance with monetary
incentives so that, in turn, the provider's quality, safety and
affordability continually improve.
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QUALITY MEASURES:
3 Prerequisites
1. File claims electronically
2. Accept electronic remittance advices through the ANSI835
transaction or retrieve remittance advices from the BCBSKS
website
3. Use the BCBSKS electronic portal for inpatient hospital
precertification and continued stay reviews
7 Quality Measures
•
3 measures require a signed attestation form only and 4 measures
require reporting.
•
Process oriented vs. outcome based
•
Incentive payment is not based on the scores submitted
QBRP TIMELINE:
• A one-time attestation form and information required for quality
measures were due December 1, 2012
• Updated information must be received no later than May 15, 2013
• Failure to report information by May 15, 2013 will result in the
reduction of the incentive previously given
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TriWest Transition
Frequently Asked Questions
Q. I'm a current TRICARE network provider. How do I contract with UnitedHealthcare so
that I may continue serving TRICARE beneficiaries?
A. We appreciate your interest in participating in the UnitedHealthcare provider network for
TRICARE and we value your service to TRICARE beneficiaries. Our primary goal is
minimizing beneficiary disruption in access to care and services. UnitedHealthcare will be
sending all currently participating TRICARE network providers a contract offer, with the
majority of offers being mailed throughout the end of October.
Q. Is there a deadline to return the documents?
A. It is recommended to return the documents as soon as possible, but no later than
December 15, 2012, to ensure each provider is set-up in time for health care delivery on April
1, 2013.
Q. Will I have to accept all UnitedHealthcare members if I sign a TRICARE contract with
UnitedHealthcare?
A. No. Our primary goal is to ensure TRICARE beneficiaries continue to be able to access
their current provider network. At this time, all UnitedHealthcare contracting activities are
specific to TRICARE program participation only.
Q. I'm not currently part of the TRICARE network but would like to be, how do I join?
A. We appreciate your interest in participation in the UnitedHealthcare TRICARE network.
•
If you are a medical provider, please contact 1-888-870-8171. A member from the
UnitedHealthcare provider relations team will contact you.
•
If you are a behavioral health provider, send an e-mail message to the
UnitedHealthcare behavioral health provider relations team at:
[email protected].
Q. What credentialing activities will be required?
A. In addition to becoming a certified provider, providers interested in signing a contract and
becoming a member of the TRICARE network must be credentialed by UnitedHealthcare. The
credentialing process involves obtaining primary-source verification of the provider's
education, board certification, license, professional background, malpractice history, and other
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pertinent data. If you are already a UnitedHealthcare participating provider, we will utilize the
credentialing information we already have on file. Should we identify additional requirements
necessary to participate in the TRICARE program, we will reach out directly to you to obtain
such information. If you are not already a participating provider, you will be required to submit
a completed application, including all necessary supporting information, and successfully
complete the credentialing process before a contract can be executed.
Q. What rates will UnitedHealthcare offer to providers?
A. UnitedHealthcare Military & Veterans is committed to balancing the delivery of a
competitively priced network to the Military Health System with fair compensation to the
provider community as they provide healthcare services to the most important of beneficiaries
- the men and women of our military and their families. If you are a current TRICARE provider,
you will receive your rate offer with your contract documents by the end of October.
Q. I'm in the middle of an appeal with TriWest; who finishes my appeal when the West
region moves under UnitedHealthcare Military & Veterans?
A. TriWest’s regional claims processor will finish appeals sent to TriWest.
Q. I currently have an authorization from TriWest to see a specialist. What happens
when the contract changes from TriWest to UnitedHealthcare Military & Veterans in the
West region? Do I need a new authorization?
A. Authorizations approved by TriWest will be valid until the end date on the authorization, or
May 30, 2013, whichever comes earlier.
Exception: TriWest and UnitedHealthcare agreed to honor existing authorizations for
maternity care for the mother’s entire 312 day episode of care, based on the start date.
Before March 31, 2013, you may need to get a new authorization from
UnitedHealthcare Military & Veterans if you need care beyond May 30, 2013. We'll have
more details about this process closer to March, 2013.
Note: At this time, you don't need to contact UnitedHealthcare about TriWest
authorizations.
Q. Is it true that TriWest is no longer the West region contractor?
A. Actually, TriWest’s current TRICARE contract continues through March 31, 2013. Effective
April 1, 2013, UnitedHealthcare Military & Veterans will be the new contractor for the West
region.
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